Provider Demographics
NPI:1457547564
Name:ROSE, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 HOPEWELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:OH
Mailing Address - Zip Code:43056-1579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:667 HOPEWELL DRIVE
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:OH
Practice Address - Zip Code:43056-1579
Practice Address - Country:US
Practice Address - Phone:740-344-6557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA 080109-LP224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2155984Medicaid